Jun 26, 2009

Chapter Challenge: QI in the Curriculum Search Results

Results Submitted by IHI Open School students & faculty

In April 2009, we asked students and facultyto explore their school’s curriculum to find out whether quality improvement and patient safety are included, and if so, where. We’d like to share a few highlights from the May Chapter Chall enge – searching for Quality Improvement in your school’s curriculum. Each school has a unique approach in teaching its students about components of quality improvement and patient safety. This is not an exhaustive curriculum search, but rather an overview of opportunities to learn about quality improvement and patient safety found by students and faculty around the world.

Duke University (Durham, North Carolina): Medical students take a week-long patient safety clinical core course between their first two clinical clerkships. There are relevant courses, such as health care quality, pay for performance, a relevant clinical core series, and a relevant clinical core week. The medical students are also required to complete a quality improvement project during their first clinical clerkship in family medicine. Lastly, the Department of Medicine faculty includes IHI videos in lectures.

Submitted by: Aasim Saeed (medical student)

University of Dundee (Dundee, Scotland): Medical students learn about quality improvement and patient safety through their foundations of medical practice, system-based learning, and task-based learning courses. A few of the lecturers who teach about QI/PS include the COO from a local hospital, an airline pilot and crew resource management expert, and a WHO "Patients for Patient Safety" champion. Currently, the medicine faculty is looking to integrate nursingstudents into a few of the medicine courses.

Submitted by: Peter Davey, MD (medicine faculty)

Instituto Tecnólogico y de Estudios Superiories de Monterrey (Monterrey, Mexico): The school has a healthcare quality improvement residency for full- time post-graduate physicians. This is a three year program developed for residents. Topics covered include communication skills, teambuilding, change and improvement, and innovation in healthcare.

Submitted by: Arturo Martinez (healthcare quality improvement resident)

Northeastern Ohio Universities Colleges of Medicine and Pharmacy (Akron, Ohio): NEOCOM integrates quality improvement teaching into the medical student clerkship topics within surgery, medicine, family medicine and obstetrics.

Submitted by: Zachary Jenkins (medical student)

Thomas Jefferson University (Philadelphia, Pennsylvania): There are two relevant courses at TJU: quality measures and outcomes analysis as well as performance improvement. Other aspects of QI/PS are integrated into several other courses, a few of which include: health policy, pharmacy practice, radiologic sciences – patient care

, and healthcare delivery systems. There is also an interclerkship day that focuses on the importance of QI/PS in clinical practice.

Submitted by: Valerie Pracilio (population health student)

University of California – San Francisco (San Francisco, California): Nursing students have the opportunity to take a course in patient safety and quality of care, nursing workforce and health systems as well as measuring outcomes of health care. Generally, QI and PS are taught as separate courses. Students in the IHI Open School Chapter have an opportunity to join local quality improvement projects

Submitted by: Roxanne O'Brien RN, MS, PhD(c) (nursing faculty)

University of Kentucky (Lexington, Kentucky): Physician Assistant students learn about QI/PS

within their clinical lecture series, clinical lab procedures, and the emergency medicine clerkship. Kentucky students also participate in the national CLARION case study competition, an interprofessional case study competition.

Submitted by: Kevin M. Schuer, MPH, PA-C (health sciences faculty)

University of Oslo (Oslo, Norway): Medical students take courses in evidence-based medicine, leadership training, and quality. Courses relevant to quality are required, not optional. Students have the option to conduct an “observe through the patient’s eyes” project during their 5th year of medical school and have the opportunity to conduce a quality improvement project during their 6th year of medical school.

Submitted by: Jo-Inge Myhre (medical student)

University of San Diego (San Diego, California): Medicine, nursing, and pharmacy students learn about QI/PS in the policy and health systems course, scope of practice in nursing course, and clinical nurse leadership course – to name a few. Nurses, pharmacists, and local guest lecturers teach these topics. Students also have the opportunity to develop a change proposal for a clinical unit within a clinical agency to improve quality of care and/or promote patient safety. They also develop and implement a community project that improves population health in a specific community. Students also have an opportunity to join a quality improvement project through the Graduate Nursing Students Association (GNSA) and the IHI Open School Chapter.

Submitted by: Ben Brenners (nursing student)

From these examples, we know quality improvement and patient safety are integrated in a variety of ways at different depths. We urge students and faculty to continue their work to integrate quality improvement and patient safety training into all health profession programs. If you would like to share your school’s quality improvement and patient safety curriculum integration, please complete the template that follows and submit to the Open School team.

Thank you to the schools that participated!

Jun 25, 2009

The difference between similar and necessary: A Medicaid definition change in CT

As states struggle to create new workable budgets during this difficult economic time, they are forced to make difficult decisions. Connecticut is currently entertaining various options for cutting governmental costs in an effort to stimulate CT’s economy, but is putting the healthcare of Medicaid enrollees in jeopardy.

CT’s Governor, M. Jodi Rell, has proposed cutting costs by changing the definition of what can legally be provided by Medicaid. Instead of paying for ‘medically necessary’ treatments, the state will only pay for the least expensive ‘medically similar’ treatment.

Not only will this proposal put a vulnerable population at increased risk, but it probably will not save on cost as much as anticipated by the Governor (and will most likely be a lot pricier in the long-run). By cutting important corners in healthcare, we are setting ourselves up to spend much more money in the long-term. For example, this will probably increase emergency department visits due to poor management of healthcare needs and less availability of healthcare providers, put more and more families into poverty as essential medical bills will not be covered, and increase the time that healthcare providers need to spend dealing with bureaucratic red tape of defending the rationale behind their treatment plans (therefore decreasing the time that they can spend with patients, and on primary care prevention, which also saves money over time).

The Governor has stated that her budget proposal serves to "take advantage of this opportunity to reshape our government and position our state to thrive when the economy rebounds." She proposes that "If we hold the line on taxes and make the tough decisions now, we will make our state infinitely more affordable for businesses and infinitely more appealing for investment. Job creation will climb as more and more companies move to- or grow in- a business-friendly Connecticut, in jobs they find here."

However the heart of this proposal aims to draw new families into Connecticut at the expense of families that are already living here. In addition, the proposal unapologeticlly aims to "improve Connecticut" by sacrificnig the services that are absolutely essential to the well-being of one of it's most vulnerable populations.

So there it is, the difference that one word can make. To me, this issue reinforces why healthcare providers need to be engaged in the political climate of their communities. As we know, policies can tremendously impact the ways in which we practice (and more importantly, impact our patients' lives!). But we seem to sometimes forget that we have a voice in these matters, and it is our responsibility to engage.

Want to learn more?
Watch television coverage here:

Read more here:

Jun 24, 2009

On Call: Paying for Performance

In his On Call presentation today, Don Berwick said he was skeptical about the effectiveness of pay for performance when it's used to motivate individuals. Among his objections:

- Pay for performance reduces the incentive for employees to cooperate with each other.
- Arriving at accurate performance metrics is tough and expensive.
- When compensation is tied to achieving targets, people tend to reach for less ambitious targets.
- It's insulting, because it presumes people won't do the right thing unless they're paid to do it.

Don recently wrote a paper about this: "The Toxicity of Pay for Performance."

What do you think about pay for performance? Would you want to be paid in this way?

(For those of you who missed Don's talk, here's the audio recording.)

Jun 23, 2009

Why no dental chapters?

It may be that I missed it or it may be that in some schools dentistry is part of a bigger faculty but it seems to me when I look through the Open School chapter list there are NO dental schools. Please feel free to let me know if I’m wrong.
Should we care? Does it matter? Well, firstly I care because I’m a dentist and secondly I care because quality and safety are vital to all health professionals not just a few. The average healthcare economy has 252 professions, including the sub-specialities. Here in Scotland we have 57 recognised professions not including nurses, dentists, doctors and pharmacists. We need to work hard to be inclusive not exclusive.
David Satcher, the US Surgeon General in 2000 called oral disease the ‘silent epidemic’. Dental caries (tooth decay) is the most prevalent preventable disease in the world.

Even a brief review of the world news today shows multiple dental stories of interest:

The BBC health pages are leading with a story outlining new evidence that there is no point in filling baby teeth. Please let me know what you think of this. Is it robust science? Should we stop filling baby teeth?

If you want to understand more about the UK’s approach to dentistry take a look at this link.

The Washington Post has a fascinating call from the US dental leaders for the reformers in the US not to forget dentistry in the drive for change.

What do you think? Should dentistry get less funding or more? Should universal insurance cover dentistry. This article contains some interesting comparisons like the fact that oral cancer kills more Americans than cervical cancer.

The delivery of dental care varies greatly around the world. Even in otherwise free systems like the UK many people pay for their dental care. Dentistry has particular challenges around quality including cross-infection, waiting times, quality of care and many more. Some have tried hard to tackle these shortcomings. Sami Bahri describes in his book 'Follow the Learner' his journey to ‘Lean’ dental practice. It’s a fascinating story of how to transform the care for a population and for a dental team. Read an interview with him here.

Please talk to your dental schools, sign them up, invite them to your meetings and encourage them to think about healthcare quality and safety.

Jun 22, 2009

On Call: Do We Need to be Paid for Quality?

Don BerwickOn Call: Do We Need to Be Paid for Quality?
Wednesday, June 24th, 4:30-5:30 PM Eastern Time

When you enter the workforce, your pay could be based on any number of factors – including how well your patients do after they enter your hospital or clinic. “Pay for performance” is an ongoing experiment aimed at motivating health care workers to do what’s right for patients. But does it do what it is supposed to do? Would you feel more motivated if your pay were linked to patient outcomes? What’s the best incentive for you to do a great job?

Join Don Berwick, IHI’s founder and CEO, as he explores the recent history and impact of pay for performance. You’ll learn:

  • How pay for performance fits into the recent history of worker incentives in health care
  • What research suggests about the effectiveness of pay for performance
  • How health systems are using (and not using) pay for performance
  • What you can do to learn more about pay structures where you work and study

Click here to register.

Jun 21, 2009

Patients Take Center Stage in Gawande's Writing

It's been nearly three weeks since Atul Gawande's article, "The Cost Conundrum," was published in The New Yorker. But the buzz and excitement has not even begun to dwindle. On the contrary, my friends who never paid any attention to health care are now asking me questions like, "So, what's with the health care costs in the US?", "What is Obama talking about?", "Dartmouth Atlas? What is that?", "Is the US going to get universal health care?", "Can we fix the incentives to reduce waste?", "Is the overuse mainly a result of practices of defensive medicine?"...

To all of my friends who have asked me questions, thank you and keep them coming! As a very soon to be medical school student, I care a great deal about health care. While I understand everyone has their own passions, it has always surprised me by how little people cared about a system that everyone has had experience with. But, thanks to Atul Gawande, I now have an excuse to blabber on ad nauseam about health care to all!

Word Cloud from Atul Gawande's "Cost Conundrum" piece

Word Cloud from Atul Gawande's University of Chicago Pritzker School of Medicine Commencement Address

Why the sudden shift in interest? The facts that Atul Gawande is a eloquent and powerful writer, Obama has made Gawande's article mandatory reading for the White House, and that it's all over the news are important factors. However, for the first time, I think the health care reform agenda is being painted in a new light. Sure, insurance and coverage are still big topics; but there are new ideas being tossed around like quality, patient-centeredness, culture of medicine, and team work. Just take a look at the word clouds of Gawande's pieces!

Most importantly, patients are now a big part of what many see as the pathway to a better health care system. What do patients need and want? How can we as health care providers and engineers of the health care system provide better care for the patients? Since we are all going to be patients at some point in our lives, these arguments hit a very personal chord. Hopefully, as we continue to search for the best health reform plan, we can all dig deep and remember the true purpose of health care and let that notion guide us.

Thanks to Ben Tseng for sending me this piece in the Washington Post with the Gawande word clouds. These images are all too powerful!

Here is another great related Atul Gawande piece that focuses on quality: "The Bell Curve" published in The New Yorker.